NCC215213_NOI Signed Certification_20210917

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload tothe electronic NOi
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division ofEnergy, Mineral N' Land Resources 8tommvvmterProgram
512N.Salisbury Street, 6thFloor (Office 64OK)
161IMail Service Center
Raleigh NC27699-16I2
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCENTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122'32]
Per NC General Statute 143-215.6B (i),any person who knowingly makes anyfalse statement, representation, or
certification inany application, record, report, plan, or other document filed or required to bemaintained under this
Article nrorule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($20,000).
Underenaltyoflaw, | certify�U
that�ec��bmmmsto|ndicagr
eement):
am the person responsible for the construction activities of this project, for satisfying the requirements of this
permit, and for any civil orcriminal penalties incurred due toviolations of this permit.
��
08 The information submitted in this NOI is, to the best ofmyknowledge and belief, true, accurate, and complete
based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information.
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u�( | will abide byall conditions ofthe NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCGO10000 General Permit, | will nonetheless ensure that all conditions ofPart ||ofthe
permit are met onthe project atall times.
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| hereby request coverage under the NCGO10000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
of United Therapeutics Lightyear
Specific Lot Numbers (must match Alb):
United Therapeutics Corporation
-Legally-Legally Responsible Organizational Entity (must match Bl): /4v Ha|pert
TitleJitle of Legally ResponsibleVp ofCorporate Real Estate
Name & Title ofSigned ifAuthorized Individual
Differs from Legally Responsible Person:
~
Signature ofLegally ResponsibV0 Person orAuthorized Individual
Date
�ie Pf—
*IMPORTANTNOTE.- This form must be signed byoresponsible corporate officer that owns moperates the construction activity,
such 000president, secretary, treasurer, urvice president, o/omanager that isauthorized hvaccordance with Part IV, Section E,